1 Impetigo13/04/2017Impetigo Clinical knowledge summaries:-http://cks.library.nhs.uk/impetigoImpetigo has unpleasant connotations to many. In the past was difficult to control and school outbreaks common.Carries stigma of “poor hygiene” and dirt – needs to be dispelledNational Prescribing Centre

2 Impetigo13/04/2017ImpetigoImpetigo is a common, highly contagious bacterial infection of the superficial layers of the epidermis.It is usually due to infection with Staphylococcus aureus or Streptococcus pyogenes, alone or together It is typically classified as either primary or secondary:Primary impetigo occurs when there is direct bacterial invasion of healthy skin.Secondary impetigo occurs when infection is secondary to some other underlying skin disease (particularly eczema, scabies) or trauma that disrupts the skin barrierUseful to ask people to describe what they understand by impetigo, at this point.The expression is often used to describe infected wounds (burns, bites etc.) – which may look similar. This isn’t discussed in these slides.Bullous impetigo is an expression often used to describe the common blistering that occurs before the yellow exudate dries and forms a crust.National Prescribing Centre

3 CKS Impetigo Guidance – Diagnosis13/04/2017CKS Impetigo Guidance – DiagnosisImpetigo causes characteristic, yellow, crusted lesions.The lesions are most commonly found on the face.Typically there are also scattered surrounding lesions, known as ‘satellite’ lesions.Under the crusts the base of the lesion is red, but there is no surrounding erythema.The person is rarely systemically unwell and the lesions are usually painless.There may be a history of contact with a person with impetigo (e.g. at school, in the family)Did the audience pick up these points?National Prescribing Centre

4 Typical appearance of impetigo in a child13/04/2017Typical appearance of impetigo in a childMost of us will recognise this – very common appearance.National Prescribing Centre

6 CKS Impetigo Guidance – How common is it?13/04/2017CKS Impetigo Guidance – How common is it?Impetigo is the most common skin infection in children.The incidence in general practice has been reported at 2.8% of all children aged 4 years and under, and 1.6 % of all children aged between 5 and 15 years.Peak incidence occurs between the ages of 2 and 6 yearsIn adults, infections in men predominate and large outbreaks may be seen in confined environments such as barracks.Important to emphasise this when seeing parents and children – also to advise not a “dirty condition” – occurs in everyone.National Prescribing Centre

7 CKS Impetigo Guidance – How should it be treated?13/04/2017CKS Impetigo Guidance – How should it be treated?Oral flucloxacillin for 7 days is the first choice oral antibiotic.Optimum length of treatment unknown, but 7 days considered reasonable (PHLS)Erythromycin is an alternative oral antibiotic if the patient is allergic to penicillins (Not included in the nurse prescriber ‘Extended Formulary’).Note local guidelines recommend clarithromycin.For a small, localized patch of impetigo, topical fusidic acid applied three times a day for 5 days is an alternative to an oral antibiotic.Generally, unless localised to one area, better to treat with oral antibiotic.Use of topical antibiotic has greater potential for causing resistance (resistance to fusidic acid is a worrying problem).An alternative strategy might be to use BOTH – generally, not to be encouraged!National Prescribing Centre

8 CKS Impetigo Guidance Should crusts be removed?13/04/2017CKS Impetigo GuidanceShould crusts be removed?It is commonly recommended that crusting skin lesions or exudates be softened, and removed if possible, by soaking in warm water or povidone-iodine prior to applying ointments.What advice on avoiding spread?Wash your hands after touching a patch of impetigo, and after applying antibiotic cream.Do not share towels, flannels, etc, until the infection has gone.Children with impetigo should stay off school or nursery until there is no further crusting.Folk-law says removing crusts is necessary. No evidence one way or another. If using topical treatment need to get into skin – may sit on top of crust.National Prescribing Centre

9 CKS Impetigo Guidance – What if the treatment is not effective?13/04/2017CKS Impetigo Guidance – What if the treatment is not effective?Check compliance with prescribed medication. Refer to GPGP advised to:-Swab to exclude other infections or resistant organisms.Rarely, streptococcus can secondarily infect lesions, and this should be suspected if treatment fails.If symptoms worsen, prescribe phenoxymethylpenicillin while awaiting test results.Do not use repeated courses of a topical antibiotic.Consider underlying disorders e.g. scabies.Infected scabies can be similar in appearance.National Prescribing Centre

10 CKS Impetigo Guidance – Patient discussion points?13/04/2017CKS Impetigo Guidance – Patient discussion points?Impetigo is not usually serious, but can spread if not treated.An antibiotic cream may be used for a small patch of impetigo.Antibiotic liquid, tablets or capsules are used if the infection is more widespread.Impetigo is contagious:Try not to touch patches of impetigo.Wash your hands if you do touch a patch of impetigo, and after applying antibiotic cream.Do not share towels, flannels, etc, until the infection has gone.Change towels frequently to stop spread of infection.Children with impetigo should stay off school or nursery until there is no further crusting.This is one of the strengths of PRODIGY – gives a useful list to talk through with carer and patient.Bit about school is often raised (but no clear evidence) – this advice is a workable compromise.National Prescribing Centre